RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01349
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20040610

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Storekeeper, medically separated for “chondromalacia patella of both knees” with a disability rating of 10%.  

CI CONTENTION:  “Review for accuracy and fairness.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the Medical Evaluation Board (MEB), but determined by the PEB to be not unfitting or non-compensable.  Any conditions outside the panel’s defined scope of review, and any contention not requested in this application, may remain eligible for future consideration by the Board for Correction of Military Records.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for the unfitting medical condition(s) at the time of separation.  The panel has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions; that role and authority is granted by Congress to the Department of Veterans Affairs, which operates under a different set of laws.  The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of disability at the time of separation.   

RATING COMPARISON:  

SERVICE PEB - 20040224	VARD - 20040726	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chondromalacia Patella of Both Knees	5099-5003	10%	Chondromalacia Patella, Right Knee	5099-5019	10%	20040430	
			Chondromalacia Patella, Left Knee	5099-5019	10%	20040430	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chondromalacia Patella of Both Knees.  The PEB combined the right and left knee conditions under a single disability rating, coded analogously to 5003 (degenerative arthritis) and rated 10%.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  

According to service treatment record and MEB narrative summary (NARSUM), the CI had a long history of bilateral knee pain, with symptoms beginning 3 months after completion of basic training in October 2001.  Physical therapy, rest, nonsteroidal anti-inflammatories, steroid injections, and two periods of limited duty (LIMDU) provided minimal symptom relief.  

The 7 November 2003 MEB NARSUM examination, 7 months prior to separation, noted complaints of chronic bilateral knee pain.  Ladder climbing, prolonged standing, kneeling and running, exacerbated her condition.  Physical examination showed mild effusion to both knees with bilateral range of motion (ROM) from 0-145 degrees (normal 0-140).  There was retropatellar tenderness and pain but no laxity or instability.  MRI revealed mild to moderate bilateral chondromalacia patella.  

During the 14 January 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported bilateral knee pain limiting prolonged standing, running or climbing ladders.  Physical examination showed bilateral knees with full ROM and no laxity, effusion, or instability.  There was bilateral retropatellar tenderness medially and inferiorly, and the CI was unable to squat or duck walk.  On 8 March 2004, she complained of knee swelling and pain while wearing boots and was given a “sneaker chit.”  

At the 30 April 2004 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI had bilateral chronic knee pain with swelling, cracking, and occasional instability.  She missed 2-3 days of work each month, but denied periods of incapacitation, and had difficulty with driving, knee bends, stair climbing, running, jumping, long standing, and walking.  Treatment consisted of knee braces, medications including narcotics, and injections.  Physical examination showed a normal gait with ROM from 0-120 degrees on the right, and 0-125 degrees on the left and no additional limitations with repetition.  There was no evidence of laxity or instability.  X-rays of both knees were normal, with prior MRI documenting bilateral chondromalacia patella.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 10%, analogously coded 5099-5003 (arthritis, degenerative).  The VA rated the right knee and left knee conditions 10% each, analogously coded 5099-5019 (arthritis, degenerative, bursitis).  The non-medical assessment, LIMDUs, NARSUM, and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either knee over the other.  Since undue speculation would be required to conclude that impairment from either knee would not have unacceptably interfered with the performance of military duties, members agreed that each knee was reasonably justified as separately unfitting.  

A bilateral 10% rating under the provisions of 5003 was considered, but the panel concluded that the NARSUM provided satisfactory evidence for swelling, the MEB showed painful motion, and the C&P evaluation confirmed evidence of limited motion of each knee; thus, separate joint ratings are indicated IAW §4.71a.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261) for either knee.  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) or history of surgery to remove a meniscus (5259) to support a rating under those codes.  There was no fracture, nonunion or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for each knee.  After due deliberation, and considering all of the evidence, the panel recommends a disability rating of 10% for the right knee condition and 10% for the left knee condition, each coded 5099-5019.  

BOARD FINDINGS:  In the matter of the bilateral knee condition, the panel recommends that each joint be separately adjudicated as follows: an unfitting right knee condition coded 5099-5019 and rated 10%, and an unfitting left knee condition, coded 5099-5019 and rated 10%, both IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chondromalacia Patella Right Knee	5099-5019	10%	
Chondromalacia Patella Left Knee	5099-5019	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160928, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs} COMMANDER, NAVY PERSONNEL COMMAND

Subj:		PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS 
Ref:	(a)	DoDI 6040.44

1.	Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (h) are approved.	The official records of the following individuals are to be corrected as follows:

a.	XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

b.	XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from
10 percent) effective date of discharge.

c.	XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

d.	XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

e.	XXXXXXXXXXXXXXXXXX, former USN: Entitlement to  disability separation pay with a 20 percent disability rating (increased from
10 percent) effective date of discharge.

f.	XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from
10 percent) effective date of discharge.

g.	XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from
10 percent) effective date of discharge.

3.	Please take action to implement these decisions and provide notification
to the above individuals once thoseact